One medication many patients take long-term following a heart attack is a beta-blocker. The drug slows the heart rate and reduces the force of cardiac contraction, easing the heart’s overall workload. However, as cardiovascular care has advanced—particularly with the widespread adoption of coronary stents—clinicians have increasingly questioned this routine practice. The central issue is whether patients whose condition remains stable after treatment still need to stay on beta-blockers indefinitely.
In a pooled analysis of large randomized clinical trials conducted in South Korea and France, researchers found that among patients without heart failure who maintained preserved cardiac function, discontinuing beta-blockers did not worsen clinical outcomes compared with continuing the medication.
A research team led by Samsung Medical Center cardiology professors Han Ju-yong and Choi Ki-hong, alongside Professor Kang Dan-bi of the hospital's Center for Clinical Epidemiology, announced on Aug. 31 that their findings were published in The Lancet. The study was conducted in collaboration with a French team led by Prof. Johan Silvain of Sorbonne University’s Pitié-Salpêtrière Hospital, part of Paris Public Hospitals (AP-HP)—Europe’s largest hospital network, operating 38 facilities in partnership with major university hospital groups.
Analysis Combines 6,238 Patients Across South Korea and France
The pooled analysis drew on data from South Korea’s "SMART-DECISION" trial and France’s "ABYSS" trial. SMART-DECISION was led by Samsung Medical Center across 25 Korean medical institutions, while ABYSS involved 49 medical centers in France. Both studies investigated whether patients who remained stable after a heart attack needed to continue beta-blocker therapy.
Together, the two trials included 6,238 patients. All participants were at least six months post-heart attack with no other clinical indications for beta-blocker therapy. None had heart failure, and all maintained a left ventricular ejection fraction (LVEF) of 40% or higher. LVEF measures how effectively the left ventricle pumps blood with each contraction and serves as a standard metric for overall cardiac function.
Researchers tracked 3,092 patients who stopped beta-blockers and 3,146 who continued them for approximately three years. Evaluating a primary composite endpoint of death, heart attack, stroke, and cardiovascular-related hospitalization, events occurred in 17.2% of the discontinuation group and 15.9% of the continuation group—a difference that was not statistically significant.
Results were virtually identical when analyzing a secondary composite outcome of death, recurrent heart attack, or heart failure hospitalization: 6.5% in the discontinuation group versus 6.4% in the continuation group.
These findings reinforce growing evidence that clinicians can safely re-evaluate long-term beta-blocker prescriptions for patients who remain stable following heart attack treatment.
"In the past, when treating heart attacks was far more difficult, long-term beta-blocker therapy was essential," Choi noted. "Recently, with modern interventions like stents, more patients recover cardiac function after a heart attack and remain stable. Safely stopping unnecessary drugs for these patients reduces the burden of lifelong daily medication."
Reassessing a 1960s Drug in the Modern Stent Era
First introduced into clinical practice in the 1960s, beta-blockers lower heart rate and contraction force to reduce myocardial oxygen demand. They remain a core therapy not only after heart attacks but also for treating angina, arrhythmias, hypertension, and heart failure.
Their therapeutic value remains indisputable for patients with reduced systolic function, active heart failure, or specific indications such as arrhythmias.
What has changed fundamentally is the surrounding clinical environment. The landmark studies that originally established routine post-heart attack use of beta-blockers predated modern standards—such as rapidly restoring blood flow with coronary stents and aggressively administering potent antiplatelet agents and statins.
As patient survival and recovery rates have dramatically improved, researchers have actively questioned whether patients with well-preserved heart function genuinely need to stay on beta-blockers over the long term.
Combining Divergent Findings From NEJM to The Lancet
The SMART-DECISION trial, a key pillar of the joint analysis, was spearheaded by the Samsung Medical Center team. Selected in 2021 as a government-funded initiative under the Ministry of Health and Welfare’s Patient-Centered Medical Technology Optimization Research Program, Professor Han conducted the study over five years in partnership with the Myocardial Infarction Research Society.
The Korean trial enrolled 2,540 stable patients across 25 hospitals who had taken beta-blockers for at least one year post-heart attack. Participants were randomly assigned to either stop or continue the medication. The estimated four-year rate for the primary composite outcome—death, recurrent heart attack, and heart failure hospitalization—was 7.2% in the discontinuation group compared to 9.0% in the continuation group, successfully meeting non-inferiority criteria.
These results were published in The New England Journal of Medicine (NEJM) in March and featured as a Late-Breaking Clinical Trial at the American College of Cardiology annual scientific session in New Orleans.
Conversely, France’s ABYSS trial—conducted across 49 centers with 3,698 patients and published in NEJM in 2024—reported primary event rates of 23.8% in the discontinuation group and 21.1% in the continuation group. Because it did not meet prespecified statistical criteria, the standalone French trial failed to demonstrate that stopping beta-blockers was non-inferior to continuing them.
By pooling raw data from both trials, the joint Korea-France study addressed these conflicting conclusions. Across 6,238 patients from two distinct nations with different demographics and healthcare systems, stopping beta-blockers caused no significant increase in major adverse clinical events.
Implications for Global Treatment Guidelines
The European Society of Cardiology (ESC) highlighted the breakthrough during the ESC Congress 2026 in Munich, Germany, on Aug. 30, where Prof. Silvain presented the integrated trial data.
Following the individual Korean trial's publication in NEJM in March, the publication of this combined dataset in The Lancet builds a compelling body of evidence to update global guidelines on long-term beta-blocker use for stable patients.
Cardiologists have long debated how long beta-blocker therapy should be maintained in patients who retain good heart function. Current U.S. clinical guidelines explicitly state that the optimal treatment duration for such patients remains uncertain.
However, experts caution that these findings do not apply universally. Patients with heart failure, significantly reduced systolic function, or ongoing indications like arrhythmias or angina require different clinical management.
Crucially, patients must not stop taking beta-blockers on their own based solely on study findings. Abrupt discontinuation can trigger dangerous rebound effects. Decisions should be made strictly in consultation with a treating physician after evaluating heart function, blood pressure, pulse, and underlying conditions.
"Through this large-scale international collaboration, we are one step closer to establishing clear clinical guidelines that allow stable patients to safely discontinue beta-blockers after a heart attack," Han said. "We hope this fosters a healthcare culture where medications are prescribed based on precise, scientific standards and reserved for those who truly benefit from them."
